restraint and seclusion education - 2013
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Restraint and Seclusion
Education - 2013 June 2013
Objectives
Upon completing this education, the nurse
should be able to:
• Distinguish the definitions of restraints and seclusions
• Identify time constraints and necessary components for
assessment and documentation
• Identify the reporting structure for Restraint and Seclusion-
related Deaths
• Demonstrate correct application of selected restraints
Restraint and Seclusion:
Definitions
• Non-violent and non-self destructive behavior • Formerly referred to as medical
• Assessment of patient indicates a medical symptom or condition that requires an intervention to promote medical healing and to protect the patient from harm
• Patient is demonstrating a lack of awareness of potential injury to self and/or attempting to remove devices used for medical management
• Order placed daily
Restraint and Seclusion:
Definitions
• Violent and self-destructive behavior • Formerly referred to as behavioral
• Patient exhibits violent or self-destructive behavior
that jeopardizes the immediate physical safety of the
patient, staff member, or others
• New order must be placed every 2 hrs for
ages 9 and older
• Visual checks completed and documented every 15
minutes
Restraint and Seclusion:
Definitions
• Chemical restraint • Drug/medication used as a restriction to manage the
patient’s behavior or restrict the patient’s freedom of
movement and is not a standard treatment or dosage
for the patient’s condition
Restraint and Seclusion:
Definitions
• Devices not considered restraints:
• Devices such as orthopedically prescribed devices,
surgical dressings or bandages, or protective helmets
• Devices or other methods that involve the physical
holding of a patient for the purpose of conducting
routine physical examinations or tests
•Devices not considered restraints:
•Devices or methods to protect the patient from falling
out of bed or to permit the patient to participate in
activities without the risk of physical harm (this does not
include a physical escort)
•Untied handmits are not a restraint and can be used as
an alternate to restraints
Restraint and Seclusion:
Definitions (cont)
Physician Order
• The attending physician shall perform an in-person assessment
of the restrained patient at least once every calendar day at
which time restraint shall be either re-ordered or discontinued
as indicated
• If a consulting physician orders a restraint, the nurse must
notify the attending physician
• The attending physician and the nurse will receive a
notification that the patient’s restraints need to be
re-ordered 4 hours before the restraint order expires
• The nurse may enter a telephone order from the physician if the
physician has completed the in-person assessment for that
calendar day
• If the order expires, you must document by adhocing the
powerform until the next order is obtained within the
calendar day
• If restraints are discontinued and then reinitiated at a later
time, a new physician order must be obtained
• ED Physician orders do not carry over onto an inpatient unit
• For ED admissions, new order must be obtained from the
attending/admitting physician upon arrival to the nursing unit
Physician Order (cont)
Physician
Downtime
Order Sheet
Restraint Initiation – Key Points
• Documentation of Restraint Initiation must be completed
• When the patient is first placed in restraints
• When the patient is admitted from the ED in restraints
• When restraints are reapplied after a previous discontinuation
• Documentation of Restraint Care Plan must be completed by all
departments
• Upon admission
• Daily after the admission plan is completed
• Use of the least restrictive means will vary from patient to
patient
Non-Violent Restraint Initiation
Removal of
“Restraint
upon arrival
from another
facility” option
If “sitter at
bedside”
chosen,
specify name
and
credentials of
the individual
Violent Restraint Initiation
Removal of
“Restraint
upon arrival
from another
facility” option
Restraint Initiation – Care Plan
Addition of link for
Care Plan
completion upon
initiation
Restraint Initiation – Care Plan
Example of
Non-Violent
Restraint
Care Plan to
be completed
upon initiation
Restraint Daily Care Plan
Example of
Non-Violent
Restraint
Care Plan
Specification of Sitter
If “sitter at
bedside”
chosen,
specify name
and
credentials of
the individual
Restraint Monitoring
Removal of
“Release” and
“Release/Reapply”
options
Assessment and Documentation
• All patients in restraints or seclusion will be assessed
and documented on approximately every 2 hours or
more frequently if indicated by the condition or behavior
of the patient
• This applies to patients in restraints for non-violent/non-
self destructive behavior and to patients in restraints for
violent/self-destructive behavior
• Proper documentation is nonnegotiable and failure to
complete will be subject to disciplinary action
Assessment and Documentation
• Assess and Document the following while explaining specific interventions attempted:
• Restraint status, location, and type
• Signs or symptoms of distress
• Signs of any injury associated with the use of the restraint
• Nutrition and hydration needs
• Circulation and skin
• Range of motion/positioning
• Hygiene and elimination
• Physical and psychological status
• Specific comfort measures taken
• Readiness for discontinuation/discontinuation attempts
• Vital signs as indicated
Assessment and Documentation
• In addition, for patients who exhibit violent and self-destructive behavior, a trained staff member will perform and document a visual check every 15 minutes, or more frequently if indicated by the condition or behavior of the patient
• Visual checks will assess for:
• Signs and symptoms of distress
• Assessment of circulation status as related to restraint application
Assessment and Documentation
• Simultaneous Restraint and Seclusion was previously known as Simultaneous Restraint or Seclusion
• Monitoring of patients in restraint and seclusion is accomplished through continuous, uninterrupted, observation by a trained staff member either:
• In person OR;
• By using simultaneous video and audio equipment
• If a staff member is physically holding the patient as the method of restraint, a second staff person is assigned
Assessment and Documentation
Do’s and Don’ts • If you must assess and/or document at a time greater
than 2 hours, DO NOT back time the entry
• DO document on the Care Plan to reflect the need for use of restraint and related interventions upon initiation and then daily
• DO NOT discontinue a restraint care plan order unless restraints are being discontinued
• DO verify restraint order is timed, dated, and is present for every calendar day
Restraint Discontinuation • Anytime the patient is removed from restraints,
document as Discontinue on the powerform
• After the discontinuation is charted on the powerform, a
nurse must discontinue the physician order for restraints
• Discontinuation is frequently forgotten with terminal extubation
• Discontinuation must be charted on the restraint powerform
for patients discharged from the hospital, regardless of
disposition
• The trial release option has been eliminated from the
hospital policy
Discontinuation Readiness
Removal of
“Comfort
Measures” plus
the addition of
more specific
“Readiness
Attempt”
choices
• Releasing a patient from restraints requires discontinuation to
be charted, as release, release/reapply, and trial release are
no longer options
• If family members request a patient be out of restraints
while they are in the room, and then for the restraints to
be reapplied when they leave, discontinuation and
reinitiation must be completed and a new order must be
obtained
• If restraints are removed while the nurse is in the room to give
care, discontinuation does not need charted and a new order
does not need to be obtained
Release, Release/Reapply,
Trial Release
Trial Release Non-Violent and Non-Self Destructive
Behavior
Before After
Trial Release Violent and Self-Destructive Behavior
Before After
• The Joint Commission Coordinator/designee must report
Restraint/Seclusion-related Deaths to the Centers for
Medicare and Medicaid Services (CMS) if:
• Death occurs:
• While the patient is in restraint or seclusion
• Within 24 hours after removal from restraint or
seclusion
• Within one week after restraint or seclusion where
the use of restraint or seclusion may have
contributed to death
Reporting of Restraint/Seclusion
Related Deaths to CMS
SBAR / Transport of Patients
Within the Facility
• If patient leaves floor in restraints, nursing must
complete a rounds report that includes:
• Type of restraint
• Reason for restraint
• Time for next restraint assessment to be completed
by area receiving the patient
• With the rounds report, nursing must send a copy of
the Restraint Downtime paper documentation form
• Area receiving patient will chart on this document
Restraint
Downtime
Documentation
Form
Placement of Restraints
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